MT 1 Flashcards
What regulates optometry
The state/provincial laws
When was the first legal DPAs allowed for optometry
1971
When did all states of DPA
by end of 1980s
When were TPAs in all states
1998
Legend drugs
A drug that requires a prescription
DEA registration
When state laws support prescribing controlled substance
Scheduled substance
controlled substance. A drug that requires an authorized prescription including the practitioners DEA. the DEA schedules a drug based on risk of dependency or abuse.
What schedule can most optometrist prescribe
Schedule III. Some allow schedule II.
What schedule may be available over the counter if state wishes it
Schedule V
Controlled substance prescription must…
be written in ink, include DEA number, date, name, and address of patient, cannot be filled past 6mo of prescription, cannot be refilled more than 5 times.
NPI Number
HIPPA mandated the adoption of number. Want to improve efficiency and tracking of prescribing.
Informed consent age
15+ Exception is 16+ for first time CL fit.
What is informed consent
Tell patient about risks of the treatment
Informed consent legal duty
- knowing when to use aspects of doctrine 2. knowing how much info you need to divulge to patient can make informed consent
standard level of care
did the patient receive the care that an average practitioner in the area would provide?
Reasonable patient
Did the optometrist provide enough info that a reasonable pt in the same situation would make a sound judgement to proceed
When does the disclosure necessary increase?
As risk increase.
Topical anesthetics or eye stains
low risk. Minimal disclosure
Dilating the pupil
Low risk except if narrow angles or pregnant.
Cycloplegia
Low risk in most cases. minimal disclosure
Therapeutic agents
higher risks. More disclosure
Disclosure of anomalies
Best to disclose all findings to the pateint
Documentation
If it isn’t written it didn’t happen. Must document what is said to patients
Confidentiality training
Review and implement patient’s rights.
Keys to good TPAs
Be a good listener. Know you patient. Have a solid diagnosis before using any risky drugs.
Prescription
A verbal, written, or electronic order for a drug issued by a properly licensed and authorized health care practitioner.
OMBRA
Mandates that pharmacists counsel all medicaid recipients
Scripts
What prescriptions are normally written in.
Prescription elements
1 Patient’s name, age and current address (no PO boxes) 2. Date on which the prescription was written (ned for II,III, IV) 3. rx symbol 4. Medication prescribed (inscription). 4. Dispensing amount (subscription) 5. Dispensing directions (signature) 6. Patient use directions 7. Refill, special labeling, other instructions 8. Prescriber’s address, signature, phone, NPI
Inscription
Line 1. Medication prescribed. Include drug name (generic or trade), strength, formulation, no abbreviations
Subscription
Line 2. Dispensing directions. Amount pharmacist will dispense (precede by dispense). Write out amount rather than numbers
Signature
Line 3. Patient use directions. Precede by sig. Best to write out in english. Include amount of drug to take each time, when to take, route of administration, how to administer, when to stop.
How many drops in each 1 ml bottle
30 dropps
Auxiliary information
Shake well before use, for external use only, for the eye, keep refrigerated, keep out of reach of children, take with food, avoid alcohol, may cause drowsiness, take on empty stomach.
should you use latin on a precription
no felcia
How much [] of trade drug does generic have to have
95%
how to indicate when you want/ do not want a prescription
Put no substitutions or generic okay
are generics capitalized
NAH
Writing percent needed
Put 0 in front of decimal point if fractional
Do you use a decimal point with a trailing zero?
No. i.e. 500 mg not 500.00 mg
Generic oral drug instructions
Must put full active ingredient, need to include dosing
Do you always need % with trade names?
No not if only one available.
Trade names capitalization
YES
Ocular Surface Dryness
A chronic, progressive, and debilitating conditions.
Symptoms of ocular surface dryness
FB sensation, redness, burning, shining, reflex tearing, fatigue
How to track ocular surface dryness
Using questionnaire: SPEED or OSDI
How prevalent is evaporative dry eye?
80%
Types of EDE
Meiobomian gland dysfunction, exposure, poor blinking, nocturnal lagophthalmos, mechanical
Signs of MGD
Classically have thickened lid margin, telangiectasia, toothpaste expression. Not all cases have these.
Clinically signs with nocturnal lagothalmos
Ask about when eyes feel driest. Ask about sleep apnea and CPAP use. Inferior staining will be gone by PM appt
Korb Meibomian Gland Evaluator
.3lbs/square inch of consistent pressure (same as complete blink). Test 3 locations across inferior lid margin for 5 sec each. Pt needs 6/24-30 to express to be asymptomatic.
Lipiview II Interferometer
Lipid layer thickness 90 nm is good). Measures complete vs. incomplete blink. >60% indicates exposure. Blink rates are reduced with near tasks.
Meibography
Infrared photography. Duct dilation (tuning fork appearance) is the first sign of problems
Eyelid Transillumination
Screening technique instead of meiobography
The orb-blackie light test for lid seal
Hold transillumination against closed light in dark room and look for light emanating.
Line of Marx evaluation
Junction between the lid and globe, lid wiper epitheliopathy, keratinized deposit stains with vital dyes.
Debridement for EDE
Remove line of marx with gold spud following instillation of topical anesthetic.
MG expression (manual) for EDE
Removes any poor meibum and inflammatory depressed. Cold expressed at 20-30 lbs/inch. Warm (110) at 10 lbs/square inch
MG expression (lipiflow) for EDE
Single 12 min therapy results in 3x gland function improvement, 2x symptoms improves. Lasts 12 months
Azasite for EDE
azithromycin 1%. Off able use for MGD associated with blepharitis. BID x3 weeks
AT lipid based
QID. EX: systane balance, refresh. Gels and ointment for nocturnal lagothalmos
PF Lipid based AT
refresh optic advanced and retain. For pt. with sensitive or who need very frequent drops
Doxycycline for EDE
Oral. Low chronic dose from 20-100mg. Start with qd X 1 month. Action is due to anti-finalmmatory problems and not AB
Azithromycin for EDE
Better than doxy for EDE. 500 mg X 1 d, 250 mg Aq X 4d. Less expensive then doxy. SE included GI upset and effect on contraceptives. Use for 5 days
Omega 3 Fatty Acids for EDE
Fish>plant sources. Triglyceride format>ethyl ester format. ALA, EPA and DHA. EPA and DHA are precursors to anti-inflammatory lipids. Want 1,000-3,000 mg/d with at lest 600 mg of EPA/DHA per 1,000 mg. Exceeding 3,000 mg can lead to excessive bleeding.
How prevalent is inflammatory dry eye
20%
Cause of IDE
Underlying systemic disease and chronic dryness
SJO test for IDE
Blood test looking for markers associated with sjogre’s. No CLIA certification needed. 89% sensitivity and 78% specificity. Includes ANA (+78% of sjogre’s pt) plus RF.
RPS inflammatory test for IDE
Detects MMP-9 on ocular surface. Diagnosis of inflammatory dry eyes. Covered by most insurances. Requires CLIA certification.
Prokera Slim
In office tx for IDE. Amniotic membrane/biologic bandage. Promotes wound healing/healthy corneal stem cells, anti-inflammatory, anti-vascularization, anti-fibrotic, anti microbial. FDA approved alternative to bandage CL. Can be used with topical. Worn 7-10d. Covered by insurance. Gets cloudy as biologics work.
Punctual plugs for aqueous deficit
Keeps tears on eyes once inflammation is under contorl
Restatsis
Topical run for IDE. Cyclosporine 0.05%. 1 get in affected eye BID. CI in patient with active ocular infection. burning in 17%. Takes 3- 6 months to start working.
Soft Steroids for IDE
Loteprednol, FML. QID for 1 mo, then taper to BID X 1 ml.
Hard steroids for IDE
pred forte. QID 1-2 wks then taper BID X 1-2 weeks then QD X 1 wk. Some docs recommend a month of steroid use prior to starting restassis to quell inflammation. Other will use them concurrently.
Testosterone for IDE
Topical cream 3% applied to upper lid QHS BID. For use in post menopausal women. Transdermal transmission. Increases lacrimal and MG function. Improves osmolarity and symptoms. Application for sjogrens patients. Off able. Need DEA.
Who is testosterone CI in?
Those with breast cancer hx or prostate cancer
Autologous Serum Eye Drops in IDE
Similar concept as prokera but hemopeotic stem cells instead of amniotic tissue. Made from serum of patients own blood. q4-6 hrs dosing. May be CI in pt with blood born infective disease. Expensive
Aqueous Artificial Tears in IDE
QID.
PF aqueous based artificial tears in IDE
QID.
Omega 3 fatty acids and IDE
ALA, EPA, DHA. EPA and DHA are precursors to anti-inflammatory. lipids. Fish is better than plant. Triglyceride formula better than ethyl ester. 1,000-3,000 mg with 600mg of EPA/DHA.
When to use what AT?
IDE=aqeuous based EDE=Lipid based
Infective dry eye
Due to blepharitis.
Underlying causes of infective dry eye
staph/strep infection. Demodex (cilia with cylindrical dandruff)
How to find demodex
tug and twirl on cilia to cause mites to suface
BlehEx
debridement, surgical grade PVC sponge dipped in lid scrub solution rotating at 1,000 RPM. Goal is to remove all exotoxins and scruff associated with demodex
Tea Tree Oils Kits
Active ingredient is 4-terpineol. Can also use melaleuca essential oil; in office kits.
Ivermactin
Broad spectrum antiparastitic for demodex infestation. 1 dose 1,000 ug/kg. Repeat after 7d.
Best treatment for EDE
blinking! Every 10-15 minutes when on device. Blink sandwich. Soft, hard soft
Modern hot compress
QD-BID X 20 min. Best is tranquileyes
Eyewear
evaporative eyewear is aimed at keeping the individual highly functional during daily activities. Can be made with rx. EX: 7-eye
Scleral CL
Reduces evaporative tears
Lid scrubs at home
Aq-BID dosing. Tea tree oil derivatives. Hypochlorous acid may or may not kill demodex but can be used for maintenance after tx. (Avenova=rxn)
Topical AB
Erythromycin 2% ung, bacitracin 2% ung, ivermectin (not yet FDA approved).
Home tx for blepharitis
Modern hot compress/lid scrubs/omega 3/ivermectin
Home tx for EDE
Modern hot compress/lid scrubs/omega 3/AB. Blink exercise/sleep shields/gel or uno PM/evaporative eyewear. Lipid based AT
Home TX for IDE
Target the inflammation (topical restatisis/pulse dose steroids/autologous serum. Rheumatological meds, omega 3) Increase healthy tear volume: Aqueous based AT, sclera CL, punctual plugs.
What causes Acute seasonal allergy conjunctivitis
Ragweed, pollen, grass, etc. 50% of allergic conjunctivitis are mildest
Signs of acute seasonal allergic conjunctvitis
itching is a hallmark sign. papillae on lower lid. Typically bilateral, can be asymmetric.
Acute Perennial allergic conjunctivitis cause
feather, dander, house dust, etc
Acute perennial allergic conjunctivas signs
typically bilateral but can be asymmetric
GPC cause
chronic inflammatory process vs. mechanical trauma. Caused by CL wear due to a combo of allergy to lens and deposits
GPC signs
cobblestone papillae on upper lid
Vernal keratoconjunctivitis cause
Chronic allergic conjunctivitis. Commonly seen in males in their teens-early 20s. Happens in warm dry climates
Vernal keratoconjunctivitis symptoms
intense itching, photophobia, irritation
Vernal keratoconjunctivitis signs
Palpebral VKC: non-uniform cobblestone. Limbal VKC: traktas’ or horners
Atopic keratoconjunctivitis cause
Excess inflammation in the skin, lining of nose and lungs. Familial tendency. Strong association with eczema and asthma
Atopic keratoconjunctivitis signs
Small/medium papillae predominantly on lower palpebral conjunctiva
Ways to deal with allergies
avoid the allergen, cold compress, AT, discussion with allergist, can try to get pt to switch from oral to nasal spray to decrease effect of orals
Mast Cell Stabilizing Antihistamines
PELBOPP. Immediate relief due to antihistamines. Long term relief requires compliance.
SE of Mast cell stabilizing antihistamines
burning/stinging, HA, bitter or metallic taste
Pregnancy and Mast Cell Stabilizers
Most are category C. Lastacraft is category B
Patanol
Mast cell stabilizer antihistamine. BID. 8 hour duration
Elestat
Mast cell stabilizer antihistamine. BID. Direct H1 receptor antagonist and an inhibitor of the release of histamine from cells
Lastacraft
QD. Approved for 2+. H1 histamine receptor antagonist.
Bepreve
BID. Approved for 2+. Highly selective H1 receptor
Optivar
BID. 8-10 hours. Larger bottle-maybe cheaper. Duration of 10 hours. Reduces the influx of inflammatory cells during the early and late phase of allergy rxn. Stings!
Pataday
Mast cell antihistamine stabilizer. During ion of 16 hours. AD. Relatively selective H1 antagonist and inhibitor of histamine.
Pazeo
Antihistamine mast cell stabilizer. QD. As effective as lastacraft. Onset of action similar to patanol and pataday but improved symptoms at 24hrs.
OTC antihistamine mast cell stabilizer
Want them with ketotifen fumarate. BID. Duration for 12 hours.
When are topical steroid useful?
Severe causes of VKC, AKC, GPC, and allergic contact dermatitis.
How do topical steroids help?
Decrease leukotriene and prostaglandin production, reduce capillary permeability, suppress lymphocyte circulation, inhibiting mast cell degranulation.
How should topical steroid use be limited?
Only to acute suppression of symptoms because of potential SE.
Alex (lotprednol 0.2%)
QID. Good for SAC. Horn’s first choice for allergic conj.
Lotemax (lotprednol 0.5%)
QID. Good for GPC and prophylaxis of SAC.
Notes about Loteprednol
Considered a site specific drug. Less likely to cause IOP spikes. Approved for allergic conjunctivitis. Rarely used alone.
Topical NSAIDs
Specifically inhibit the enzyme cyclooxyrgenase which blocks the production of prostaglanis from arachidonic acid metabolism. Alter the patient’s sensitivity to itch. May be helpful if patient won’t take steroids.
Acular (keterolac 0.5%)
Up to QID. Onset of relief within an hour. Only NSAID approved for treatment of itch. Works as an analgesic to decrease pain.
Acular LS (Keterolac 0.4%)
Lower concentration so less sting
Acular PF
More expensive but preservative free so less sting.
Oral Antihistamines
Should be prescribed with significant nasal problems. Have drying effect on ocular surface (decrease tear production by lacrimal gland and decreased mucin production)
Zyrtect
Oral Antihistamine. 5 & 10 mg tabs QD. Onset in 15-30 minutes. Available OTC but very expensive. Duration 4-24 hours.
Allegra
60 mg tabs PO BID. 180 mg tabs PO QD. Available OTC.
Clarinex
5 mg tab PO QD.
Ocular Allergy Antihistamine Decongestant Combo
OTC. used in mild cases. Antihistamine help suppress the immunological response. Approved for 6YO. Duration of 4 hours.
Vasocon
Ocular allergy antihistamine decongestant combo. QID. RXN only.
Opcon, naphcon, visine
ocular allergy antihistamine decongestant combo. QID
Vision AC
ocular allergy antihistamine combo. TID.
Topical decongestants
OTC. Temporary relief. Used in mild cases. Not the best choice. Reduce chemises and conjunctival hyperemia. Have rebound redness.
Topical decongestants
Phenylephrine, Naphalozine, Tetrahydrozaline. oxymetazoline.
Mast cell stabilizer
It takes awhile for drugs to work. Can be used for months without any SE
Alocril
Mast cell stabilizer. BID. Warn pt of yellow color. inhibits eosinophils, neutrophils, and macrophils
Alamast
Mast cell stabilizer. BID.
topical intranasal corticosteroids
Are more effective than oral antihistamines in controlling nasal blockage. Long term se can lead to elevated IOP and cataracts. Use of nasal spray + topical allergy drop more effective than nasal spray + oral antihistamine.
cyclosporine
immunosuppresents. Systemic administration may be effective treatment of severe AKC.
Similasan’s eye drop
homeopathic. No research showing efficacy.
Types of human herpes viruses
alpha, beta, gamma
What are all commercially available anti-vitals?
virustatic. Inhibit specific steps in the process of viral DNA replication in virally infected cells.
Trifluridine
Generic available. 1gtt g2hrs while awake (Max 9 d) until corneal ulcers has reepitheliazed followed by 1 get q4hrs while awake for another 7d. Used to be drug of choice for HSV epithelial keratitis. Use with 6yo. Category C.
Gancyclovir
topical anti-viral. 1gtt 5xd until dendritic ulcer resolves then 1gtt TID for additional 7d. 2 YO+. Drug of choice for HSV epithelial keratitis.
What is drug of choice for HSV epithelial keratitis?
Gancylcovir
Betadine solution
Use with EKC. 1gtt propairicane first. 4-5 get betadine.
Acyclovir
Oral antiviral. 800 mg 5Xd for 7d with HZS. 400 mg 5Xd for 7d with simplex.
Valcyclovir
1,000 mg 3X/d for 7d for HZV. 500 mg 3Xd for HSV. Prodrug of acyclovir.
Famciclovir
Greg. category B. 500 mg 3Xd for 7d for HZV. 250 mg 3xd for 7d for HSV. Pro drug of penciclovir
Valganiclovlir
Use for long term mgmt of CMV retinitis in patients with AIDS.
Zostavax
Herpes zoster (shingles) vaccine. FDA approved. Used to prevent shingles in adults 60 YO.
HSV vaccines
Undergoing clinical trials.
Herpetic Eye Disease Study
Show that long term suppressive therapy with an oral anti viral reduced recurrence of HSV, reduced stratal recurrence by 50% among its who had the infection in the previous year.
Treating HSV epithelial keratisis
Topical is sufficient
Treat HSV storm keratisi
Oral
Enothelitis
Topical pred
Keratouveitis
topical pred
Sodium sulfacetamide
don’t use. mucopurelent hampers its effectivity.
Besivance
AB. Broad spectrum. TID X 7 d.
floxacin
fluroquinalones.
ciprofloxacin
only uno available.
Doxycycline
Tetracycline. Inhibits protein synthesis. CI with pregnancy and lactation.
Augmentin
Amoxicillin and clavulanic acid.
Bacitracin
ung. use with blepharitis.
Polysporin
bacitracin/polymyxin.
Polytrim
broad spectrum. Solution only. Excellent AB for treating bacterial conj. Minimally toxic to the eye. High efficient against the most common cause of eye infection in peds
Aminoglycosides
gentamicin and tobramycin.
Tobradex
AB/Steroid. 1-2 get q4-6 hours
Macrolides
Azasite, erythromycin, clarithromycin. ACE.
